Final Care Coordination Plan

For this assessment, you will simulate implementation of the preliminary care coordination plan you developed in Assessment 1. The presentation would be structured for the hypothetical patient.

NOTE: You are required to complete this assessment after Assessment 1 is successfully completed.

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Care coordination is the process of providing a smooth and seamless transition of care as part of the health continuum. Nurses must be aware of community resources, ethical considerations, policy issues, cultural norms, safety, and the physiological needs of patients. Nurses play a key role in providing the necessary knowledge and communication to ensure seamless transitions of care. They draw upon evidence-based practices to promote health and disease prevention to create a safe environment conducive to improving and maintaining the health of individuals, families, or aggregates within a community. When provided with a plan and the resources to achieve and maintain optimal health, patients benefit from a safe environment conducive to healing and a better quality of life.

This assessment provides an opportunity to research the literature and apply evidence to support what communication, teaching, and learning best practices are needed for a hypothetical patient with a selected health care problem.

You are encouraged to complete the Vila Health: Cultural Competence activity prior to completing this assessment. Completing course activities before submitting your first attempt has been shown to make the difference between basic and proficient assessment.

Demonstration of Proficiency

By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

Competency 1: Adapt care based on patient-centered and person-focused factors.
Design patient-centered health interventions and timelines for care delivered through direct clinical interaction that is logged in the CORE ELMS system.
Competency 2: Collaborate with patients and family to achieve desired outcomes.
Use the literature on evaluation as a guide to compare learning session content with best practices.
Competency 3: Create a satisfying patient experience.
Describe what the literature says about effective care coordination and patient satisfaction verses experience, including how to align teaching sessions to the Healthy people 2020 document..
Competency 4: Defend decisions based on the code of ethics for nursing.
Make ethical decisions in designing patient-centered health interventions.
Competency 5: Explain how health care policies affect patient-centered care.
Identify relevant health policy implications for the coordination and continuum of care.
Preparation

In this assessment, you will implement the preliminary care coordination plan you developed in Assessment 1 and communicate the plan to the hypothetical patient in a professional, culturally sensitive, and ethical manner.

To prepare for the assessment, consider the patient experience and how you would present the plan.

Note: Remember that you can submit all, or a portion of, your plan to Smarthinking Tutoring for feedback, before you submit the final version for this assessment. If you plan on using this free service, be mindful of the turnaround time of 24–48 hours for receiving feedback.

Instructions

Note: You are required to complete Assessment 1 before this assessment.

For this assessment:

Build on the preliminary plan, developed in Assessment 1, to complete a comprehensive care coordination plan.
Document Format and Length
Build on the preliminary plan document you created in Assessment 1. Your final plan should be 5–7 pages in length.

Supporting Evidence
Support your care coordination plan with peer-reviewed articles, course study resources, and Healthy People 2020 resources. Cite at least three credible sources.

Grading Requirements
The requirements, outlined below, correspond to the grading criteria in the Final Care Coordination Plan Scoring Guide, so be sure to address each point. Read the performance-level descriptions for each criterion to see how your work will be assessed.

Design patient-centered health interventions and timelines for care.
Address three patient health issues.
Design an intervention for each health issue.
Identify three community resources for each health intervention, so the patient may make an informed decision about what resources to use.
Consider ethical decisions in designing patient-centered health interventions.
Consider the practical effects of specific decisions.
Include the ethical questions that generate uncertainty about the decisions you have made.
Identify relevant health policy implications for the coordination and continuum of care.
Cite specific health policy provisions.
What does the literature say about evaluation in care coordination?
How might revisions to the plan improve future outcomes?
What does literature say about:
Effective care coordination and patient satisfaction verses experience?
How to align teaching sessions to the Healthy People 2020 document?
Additional Requirements
Before submitting your assessment, proofread your final care coordination plan to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your plan.

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